| Doctor Name: | BERNICE WILSON |
| NPI Number: | 1649458662 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 32001561A |
| Business Practice Address: | 4202 Buell Dr Fort Wayne, IN - 468072743 |
| Business Phone Number: | 2603414756 |
| Business Fax Number: | |
| Mailing Address: | 4202 Buell Dr, FORT WAYNE |
| State: | IN |
| Postal Code: | 468072743 |
| Phone Number: | 2603414756 |
| Fax Number: | |
| NPI Enumeration Date: | 01/31/2008 |
| NPI Last Update Date: | 01/31/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | 32001561A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |